Coronary artery disease
Impact of Thrombectomy With EXPort Catheter in Infarct-Related Artery During Primary Percutaneous Coronary Intervention (EXPIRA Trial) on Cardiac Death

https://doi.org/10.1016/j.amjcard.2010.04.014Get rights and content

In ST-segment elevation myocardial infarction (STEMI) impairment of microcirculatory function is a negative independent predictor of myocardial function recovery. In the Impact of Thrombectomy with EXPort Catheter in Infarct-Related Artery during Primary Percutaneous Coronary Intervention (PCI; EXPIRA) trial we found that manual thrombectomy resulted in a better myocardial reperfusion expressed by an improved procedural outcome and a decrease of infarct size compared to conventional PCI. The aim of the present study was to investigate whether the early efficacy of thrombus aspiration translates into very long-term clinical benefit. We randomized 175 patients with STEMI with occlusive thrombus at baseline undergoing primary PCI to thromboaspiration with a manual device (Export Medtronic, n = 88) or standard PCI (n = 87). No differences in baseline, clinical, and angiographic preprocedural findings were observed between the 2 groups except for incidence of hypertension and cholesterol levels. After 24 months major adverse cardiac events were 13.7% versus 4.5% (p = 0.038, log-rank test) and cardiac death was 6.8% versus 0% (p = 0.012, log-rank test). A strict correlation was observed between cardiac death incidence and tissue reperfusion parameters (postprocedural myocardial blush grade and ST-segment resolution). In conclusion, manual thrombus aspiration before stenting of the infarct-related artery in selected patients with STEMI improving myocardial reperfusion significantly decrease cardiac death and major adverse cardiac events at 2 years.

Section snippets

Methods

Details of the EXPIRA trial have been previously reported.11 EXPIRA investigated whether thrombus aspiration as adjunctive therapy in PPCI was better than standard PCI in patients with STEMI and angiographic evidence of a large thrombus burden. The trial was a single-center, randomized, open study with blinded assessment of end points.

One hundred seventy-five consecutive patients admitted with STEMI and candidates for PPCI were enrolled at the Policlinico Umberto I, “Sapienza” University of

Results

Baseline clinical and angiographic characteristics were well-balanced between the 2 groups with the exception of hypertension, smoke and cholesterol levels. Procedural angiographic results previous published are also reported11 (Table 1).

Written questionnaires to obtain information on vital status, hospital admissions, and current medical therapy were available for all patients in each group.

No significant differences in current medical therapy were observed between groups at 2-year follow-up (

Discussion

For the first time a very long-term follow-up (>1 year) was assessed in the setting of PPCI treated with adjunctive manual thrombectomy.

The main finding of the present study is that pretreatment with manual thrombectomy during PPCI results in a lower cardiac mortality and a lower incidence of other MACEs at 2-year follow-up than conventional therapy alone.

PPCI with stent implantation and pretreatment with abciximab is currently the preferred revascularization strategy in patients with STEMI.1, 2

References (31)

  • G.W. Stone et al.

    Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction

    J Am Coll Cardiol

    (2002)
  • D. Antoniucci et al.

    Abciximab-supported infarct artery stent implantation for acute myocardial infarction and long-term survivalA prospective, multicenter, randomized trial comparing infarct artery stenting plus abciximab with stenting alone

    Circulation

    (2004)
  • F. Zijlstra et al.

    Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction

    N Engl J Med

    (1999)
  • C.L. Grines et al.

    Coronary angioplasty with or without stent implantation for acute myocardial infarction

    N Engl J Med

    (1999)
  • L. De Luca et al.

    Impact of intracoronary aspiration thrombectomy during primary angioplasty on left ventricular remodelling in patients with anterior ST-elevation myocardial infarction

    Heart

    (2006)
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      Thrombectomy during acute MI has shown conflicting results. There is some evidence that manual thrombectomy can reduce infarct size and preserve microvascular integrity as assessed by CMR [62]. On the other hand, a meta-analysis suggested that it may be associated with harm [63].

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    Dr. Sardella and Dr. Mancone contributed equally to this article.

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